Doctors' Duties When Prescribing Marijuana

As we wrote about here, the College of Physicians and Surgeons of Ontario (“CPSO”) recently approved a new policy, Marijuana for Medical Purposes (“the MMP Policy”), which outlines the CPSO’s expectations for all physicians who prescribe dried marijuana for medical purposes and because of legalization, they offer this. This article highlights physicians’ obligations under the MMP Policy.

1. Physicians' Obligations Before Prescribing

Assessing the appropriateness of dried marijuana for the patient

The MMP Policy advises physicians that before prescribing dried marijuana, they must carefully consider whether it is the most appropriate treatment for their patient, taking into account the available evidence in support of dried marijuana and weighing it against other available treatment options, such as doing a vape pen review and treating their patients with vaporized cannaboid oils.

Physicians are also obliged to consider the risks associated with the use of dried marijuana. They must comply with the applicable standard of practice when assessing risk and take such steps as are clinically indicated in the specific circumstances of each case to mitigate identified risks. The MMP Policy lists some of the recommended components of a risk assessment, which are provided for in the literature, including:

1. an assessment of each patient for their risk of addiction and substance diversion; and

2. an assessment of risk factors for psychotic disorders, mood disorders and other mental health issues that may be affected by the use of dried marijuana.

consent discussion

Prescribing to patients under the age of 25According to the MMP Policy, physicians must not prescribe dried marijuana to patients under the age of 25 unless all other conventional therapeutic options have been exhausted. This guideline appears to be based on current evidence that the risk for marijuana-associated harms – such as suicidal ideation, illicit drug use, cannabis use disorder, and long-term cognitive impairment – is greater in children, adolescents, and young adults who consume dried marijuana than in older adults.Obtaining informed consentThe CPSO reminds physicians in the MMP Policy that they must always obtain valid and informed consent to treatment in accordance with their legal obligations under the Health Care Consent Act, 1996 and the CPSO’s Consent to Treatment policy.Informed consent involves, at a minimum, the following components:

1. Advising patients about the material risks and benefits of dried marijuana, which include:

1. effects and interactions;

   1. material side effects;

   2. contraindications;

   3. precautions; and

   4. any other information pertinent to its use.

2. Cautioning all patients who engage in activities that require mental alertness about the potential that they may become impaired while using marijuana.The MMP Policy also recommends that physicians explain to the patient the extent and quality of the evidence that forms the basis for the physician’s understanding of the appropriateness of dried marijuana as a treatment for the patient’s clinical condition. In other words, physicians should disclose to patients the extent of their own knowledge about marijuana as a treatment option and the fact that there is limited evidence available to support the efficacy of the use of marijuana to treat certain conditions.Physicians' Obligations When PrescribingDetermining a safe and effective doseThe MMP Policy explains that determining a safe and effective dose of dried marijuana for each patient may be challenging, given that current research demonstrates that patient sensitivities to the psychoactive and therapeutic effects of the drug vary substantially.The CPSO recommends that physicians initiate treatment with a low quantity of dried marijuana and begin by prescribing only those strains that are low in THC, the psychoactive compound in marijuana. Physicians may then incrementally increase the quantity and/or prescribe strains higher in THC in order to effectively manage the patient’s symptoms, but at the same time minimizing any associated euphoria or cognitive impairment. The medical document prepared by the physician must specify the quantity of dried marijuana as well as the THC content.Managing the risk of abuse, misuse and diversionThis section of the MMP Policy advises physicians to follow the guidelines for managing the risk of abuse, misuse and diversion of narcotics and controlled substances set out in the CPSO’s Prescribing Drugs policy.The CPSO also recommends that physicians require all patients to whom they prescribe dried marijuana to sign a written treatment agreement, delineating the key aspects regarding adherence to the prescribed treatment. According to the MMP Policy, the treatment agreement should contain, at a minimum, a statement from the patient that they:

1. will not seek dried marijuana from any other source;

2. will only use dried marijuana as prescribed;

3. will store their dried marijuana in a safe and secure manner; and

4. will not sell or give away their dried marijuana.

The written treatment agreement should also contain a statement that if the agreement is breached, the physician has the authority to decide to cease prescribing marijuana to the patient.The CPSO also advises that physicians must monitor all patients to whom they prescribe dried marijuana for any emerging risks or complications, and must discontinue prescribing where the dried marijuana no longer meets the physician’s therapeutic goals or where the risks of the dried marijuana outweigh the benefits to the patient.3. Charging FeesAs outlined at the beginning of the MMP Policy, the CPSO considers the medical document authorizing patient access to dried marijuana under the MMPR to be equivalent to a prescription. The assessment of a patient’s medical condition is an insured service for which the physician bills OHIP, and the determination of whether dried marijuana is the most appropriate treatment and the preparation of the medical document is part and parcel of this insured service. Accordingly, physicians are not permitted to charge patients a fee for completing the medical document. Nor may physicians charge for any activities associated with completing the medical document for the patient, including, but not limited to:

1. assessing the patient;

2. reviewing the patient’s chart; and

3. educating or informing the patient about the risks or benefits of marijuana.

ConclusionAs set out in the Marijuana for Medical Purposes Policy, physicians are not obligated to prescribe dried marijuana where they do not believe it is clinically appropriate for their patient, they also have the right to recommend places like the Montreal compassion center as long as they consider it is appropriate for the patient. All physicians who choose to do so, however, must adhere to the guidelines set out in the MMP policy. Physicians prescribing marijuana for patients must ensure that they educate themselves sufficiently in order to obtain informed consent from patients.  This means being sufficiently knowledgeable about marijuana as a medical treatment and the strains available in order to explain these to patients, and to determine a safe and effective dose for patients beginning this treatment. Physicians should also obtain advice regarding this aspect of their practice and particularly around any fees they propose to charge to patients in connection with this treatment. For further information regarding this policy and/or the regulations regarding medical marijuana, please contact us.